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Based on observation, interview, record review and policy review, the facility failed to ensure that nursing staff developed individualized care plans as directed by facility policy for 10 patients (#10, #13, #14, #15, #20, #21, #31, #34, #43, and #50) of 25 patients evaluated for appropriate plans of care. This failure increased the potential for miscommunication regarding patient care, which increased the potential for all inpatients to receive substandard care. The facility census was 372.

Findings included:

1. Record review of the facility policy titled, "Interdisciplinary Plan of Care," dated 05/07/13, showed the Interdisciplinary Plan of Care (IPOC) was to:
- Ensure optimal outcomes for the patient;
- Allow a variety of disciplines (including nursing) to share assessments, goals, and interventions in one place in the electronic medical record (EMR);
- Provide a centralized location to establish and document patient goal progression;
- Be individualized for each patient with goals and interventions focused on individual patient needs;
- Be changed as the needs of the patient changed;
- Be initiated by the Registered Nurse (RN);
- Be reviewed and documented in by nurses at least once a shift; and
- Be used during shift handoff (transfer of patient care responsibility from one nurse to another) and modified as needed.
Procedure changes for Nursing Staff:
- The IPOC format will provide a centralized location to establish and document patient goal progression.
- IPOC goals will be more focused on specific patient needs, rather than a reflection of standards of care.
- IPOC will replace the current Management Protocols and Patient Care Goals documentation in Power Chart.

The policy contained no direction to staff that there were any exceptions to these procedures.

Further record review of the facility policy titled, "Interdisciplinary Plan of Care," dated 05/07/13, showed various IPOC plans available in the EMR. The plans had goal and intervention choices for individual patient needs. The IPOC plans included those for:

- Cardiovascular (having to do with the heart and blood vessel system);
- Endocrine (having to do with the hormonal system; e.g. diabetes);
- Gastrointestinal/Genitourinary (GI-having to do with the stomach and intestines/GU-having to do with the genitals and urinary system);
- Musculoskeletal (having to do with the muscles and skeleton);
- Neurological (having to do with the nervous system);
- Nutrition;
- Pain;
- Psychosocial;
- Pulmonary (having to do with the lungs);
- Safety;
- Skin and Wound; and
- Spiritual.

2. Observation on 03/04/14 at approximately 10:30 AM on the Family Medicine Unit showed Patient #14 with an indwelling urinary catheter (tube to remove urine from the bladder) for urinary retention.

3. Record review of Patient #14's IPOC showed the GI/GU plan did not include nursing goals and interventions appropriate for urinary catheter.

4. During an interview on 03/04/14 at approximately 10:30 AM, Staff N, Clinical Supervisor, and Staff M, RN Manager, stated that Patient #14's GI/GU plan should include nursing goals and interventions for urinary catheter. Staff N further stated that the purpose of the IPOC is to make sure that everyone is working together toward the patient's goals.

5. Record review of Patient #13's medication administration record (MAR) on the Behavioral Health Unit showed a physician order for Triple Antibiotic Ointment (TAO, a medication applied to skin to treat and/or prevent infection and promote healing) applied to the left wrist wound two times daily.

6. Record review of Patient #13's IPOC showed no nursing goals, interventions or planned assessment for skin or wound care.

7. During an interview on 03/04/14 at 10:55 AM, Staff W, Licensed Practical Nurse (LPN), stated that Patient #13 had a history of self destructive behavior and cutting herself. She stated that Patient #13 had wounds on her left wrist from cutting herself and that she applied TAO and a dressing to the patient's wrist two times daily. She further stated that she only administered medications and had not documented any assessment in the patient's record about the wound and did not know if the nursing care related to the wound or wound care had been placed on the IPOC.

8. Observation on 03/04/14 at approximately 11:30 AM on the Medicine Unit showed Patient #15 receiving intravenous (IV, into the vein) antibiotics for pneumonia (infection of the lungs).

9. Record review of Patient #15's IPOC showed no Pulmonary plan with nursing goals and interventions appropriate for pneumonia.

10. During an interview on 03/04/14 at approximately Noon, Staff R, RN assigned to Patient #15, and Staff Q, Clinical Supervisor, stated that the IPOC should include the Pulmonary plan with nursing goals and interventions appropriate for pneumonia. Staff Q further stated that the purpose of the IPOC is to make sure that everyone is working together toward the patient's goals.

11. Observation on 03/04/14 at approximately 2:00 PM on the Surgical Specialties Unit showed Patient #20 with an indwelling feeding tube in the stomach to provide liquid nutrition because of swallowing difficulty.

12. Record review of Patient #20's IPOC showed no Nutrition plan with nursing goals and interventions appropriate for feeding tube.

13. During an interview on 03/04/14 at approximately 2:00 PM, Staff DD, RN assigned to Patient #20, Staff BB, RN Clinical Supervisor, and Staff CC, RN Manager, stated that the IPOC should include the Nutrition plan with nursing goals and interventions for feeding tube. Staff DD further stated that the purpose of the IPOC is to make sure that everyone is working together toward the patient's goals.

14. Observation on 03/04/14 at approximately 2:30 PM on the Neurological Unit showed Patient #21 receiving IV blood thinner for a deep vein thrombosis (DVT, blood clot in the lower leg vein).

15. Record review of Patient #21's IPOC showed no Cardiovascular plan with nursing goals and interventions appropriate for DVT.

16. During an interview on 03/04/14 at approximately 2:30 PM, Staff FF, RN assigned to Patient #21, and Staff EE, RN Clinical Supervisor, stated that the IPOC should include the Cardiovascular plan with nursing goals and interventions for DVT. Staff FF further stated that the purpose of the IPOC is to make sure that everyone is working together toward the patient's goals.

17. Observation on 03/05/14 at approximately 9:00 AM on the Cardiology Unit showed Patient #34 expecting a blood transfusion for blood abnormalities.

18. Record review of Patient #34's IPOC showed it was established by Staff OO, Clinical Supervisor, and did not include the Cardiovascular plan with nursing goals and interventions appropriate for blood transfusion.

19. During an interview on 03/05/14 at approximately 9:00 AM, Staff OO stated that the IPOC should include the Cardiovascular plan with nursing goals and interventions appropriate for blood transfusion in Patient #34's IPOC. Staff OO further stated that the purpose of the IPOC is to make sure that everyone is working together toward the patient's goals.

20. Observation on 03/05/14 at 9:15 AM on the Cardiac Intensive Care Unit (ICU) showed open wounds on Patient #31's upper back.

21. Record review of Patient #31's IPOC showed no Skin/Wound plan with nursing goals and interventions appropriate for the patient's back wounds.

22. During an interview on 03/05/14 at approximately 9:30 AM, Staff TT, RN, stated that the IPOC should include the Skin/Wound plan with nursing goals and interventions appropriate for Patient #31's back wounds.

23. Observation on 03/05/14 at approximately 11:30 AM on the Surgical ICU showed Patient #43 receiving dialysis (medical procedure to remove wastes from the blood by filtering through a machine) for kidney failure.

24. Record review of Patient #43's IPOC showed the GI/GU plan did not include nursing goals and interventions appropriate for dialysis.

25. During an interview on 03/05/14 at approximately 12:30 PM, Staff HHHH, RN Educator, confirmed that Patient #43's IPOC did not include nursing goals and interventions appropriate for dialysis.

26. Record review of Patient #10's EMR showed:

- He was admitted on 02/28/14 to the Orthopedic Department (OD) with a hematoma (a solid swelling of clotted blood within the tissue) in the right hip.
- He was discharged on 02/26/14 from a psychiatric unit with a diagnosis of agitation and threats to harm others.
- His past medical problems included depression and anxiety.
- The IPOC did not include the Psychosocial plan with goals and interventions appropriate for psychiatric issues.

27. During an interview on 03/04/14 at 10:45 AM, Patient #10 stated that he could not be discharged from the hospital because no other facility would take him. He stated that the Home Health Social Worker had said that he had threatened to kill the Governor. He stated that he did not say that and that the Social Worker had made that up. He stated that he was taken to a Psychiatric facility on a 96 hour hold (an involuntary commitment in order to evaluate a patient) by the police. He stated that he had met with the Home Health Social Worker in the parking lot of the hospital two days ago to discuss this. He stated that he was not getting his Social Security checks because someone had closed his account.

28. During an interview on 03/05/14 at 1:15 PM, Staff K, OD Director of Nursing (DON), stated that she expected her staff to implement a care plan regarding Patient #10's agitation and anxiety.

29. During an interview on 03/05/14 at 1:35 PM, Staff UU, RN, stated that Patient #10 definitely had anxiety at times but he was unaware that the patient had any psychiatric issues before admission to the unit.

30. During an interview on 03/05/14 at 1:50 PM, Staff VV, RN, stated that a care plan for anxiety could have been implemented and it might have been helpful to have that information prior to caring for Patient #10.

31. During a phone interview on 03/05/14 at 3:12 PM, Staff III, RN, stated that a care plan for anxiety for Patient #10 would have been helpful so all the staff were on the same page. Staff III stated that she failed to add a care plan regarding Patient #10's anxiety because she rarely cared for patients with psychiatric issues.

32. Observation on 03/05/14 at approximately 1:30 PM on the Surgical ICU showed Patient #50 with a new surgical colostomy (an artificial opening from the large intestine to the surface of the abdomen).

33. Record review of Patient #50's IPOC showed no GI/GU plan with nursing goals and interventions appropriate for colostomy.


34. During an interview on 03/05/14 at approximately 1:30 PM, Staff JJJ, RN, stated that no care plan was needed for this new patient as care would be covered by nursing protocols.

35. During an interview on 03/04/14 at approximately 9:00 AM, Staff PP, RN Manager of Trauma and ICU, stated that:

- Nursing staff were instructed that the IPOC is to be used for exceptions to nursing protocols.
- Nursing staff were instructed that care related to an order or a nursing protocol does not need to be included in the IPOC.
- She agreed the IPOC may not reflect all the patient's needs if that care is omitted.

36. During an interview on 03/05/14 at 10:30 AM, Staff C, Chief Nurse Executive (CNE), stated that it is her understanding nursing staff do not need to include care related to an order or a nursing protocol in the IPOC although this is not in policy. She agreed the IPOC may not reflect all the patient's needs if that care is omitted.

37. During an interview on 03/05/14 at 2:30 PM, Staff GGGG, Practice and Standards Coordinator, stated that:

- She educates nursing staff on use of the IPOC.
- Nursing staff were instructed that the IPOC is to be used for exceptions to nursing protocols.
- Nursing staff were instructed that care related to an order or a nursing protocol does not need to be included in the IPOC.
- When given the example of Patient #15, she agreed that nurses should have included the Pulmonary plan in the patient's IPOC with a respiratory goal established.


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Based on observation, interview, record review and policy review, the facility failed to ensure that nursing staff developed individualized care plans as directed by facility policy for 10 patients (#10, #13, #14, #15, #20, #21, #31, #34, #43, and #50) of 25 patients evaluated for appropriate plans of care. This failure increased the potential for miscommunication regarding patient care, which increased the potential for all inpatients to receive substandard care. The facility census was 372.

Findings included:

1. Record review of the facility policy titled, "Interdisciplinary Plan of Care," dated 05/07/13, showed the Interdisciplinary Plan of Care (IPOC) was to:
- Ensure optimal outcomes for the patient;
- Allow a variety of disciplines (including nursing) to share assessments, goals, and interventions in one place in the electronic medical record (EMR);
- Provide a centralized location to establish and document patient goal progression;
- Be individualized for each patient with goals and interventions focused on individual patient needs;
- Be changed as the needs of the patient changed;
- Be initiated by the Registered Nurse (RN);
- Be reviewed and documented in by nurses at least once a shift; and
- Be used during shift handoff (transfer of patient care responsibility from one nurse to another) and modified as needed.
Procedure changes for Nursing Staff:
- The IPOC format will provide a centralized location to establish and document patient goal progression.
- IPOC goals will be more focused on specific patient needs, rather than a reflection of standards of care.
- IPOC will replace the current Management Protocols and Patient Care Goals documentation in Power Chart.

The policy contained no direction to staff that there were any exceptions to these procedures.

Further record review of the facility policy titled, "Interdisciplinary Plan of Care," dated 05/07/13, showed various IPOC plans available in the EMR. The plans had goal and intervention choices for individual patient needs. The IPOC plans included those for:

- Cardiovascular (having to do with the heart and blood vessel system);
- Endocrine (having to do with the hormonal system; e.g. diabetes);
- Gastrointestinal/Genitourinary (GI-having to do with the stomach and intestines/GU-having to do with the genitals and urinary system);
- Musculoskeletal (having to do with the muscles and skeleton);
- Neurological (having to do with the nervous system);
- Nutrition;
- Pain;
- Psychosocial;
- Pulmonary (having to do with the lungs);
- Safety;
- Skin and Wound; and
- Spiritual.

2. Observation on 03/04/14 at approximately 10:30 AM on the Family Medicine Unit showed Patient #14 with an indwelling urinary catheter (tube to remove urine from the bladder) for urinary retention.

3. Record review of Patient #14's IPOC showed the GI/GU plan did not include nursing goals and interventions appropriate for urinary catheter.

4. During an interview on 03/04/14 at approximately 10:30 AM, Staff N, Clinical Supervisor, and Staff M, RN Manager, stated that Patient #14's GI/GU plan should include nursing goals and interventions for urinary catheter. Staff N further stated that the purpose of the IPOC is to make sure that everyone is working together toward the patient's goals.

5. Record review of Patient #13's medication administration record (MAR) on the Behavioral Health Unit showed a physician order for Triple Antibiotic Ointment (TAO, a medication applied to skin to treat and/or prevent infection and promote healing) applied to the left wrist wound two times daily.

6. Record review of Patient #13's IPOC showed no nursing goals, interventions or planned assessment for skin or wound care.

7. During an interview on 03/04/14 at 10:55 AM, Staff W, Licensed Practical Nurse (LPN), stated that Patient #13 had a history of self destructive behavior and cutting herself. She stated that Patient #13 had wounds on her left wrist from cutting herself and that she applied TAO and a dressing to the patient's wrist two times daily. She further stated that she only administered medications and had not documented any assessment in the patient's record about the wound and did not know if the nursing care related to the wound or wound care had been placed on the IPOC.

8. Observation on 03/04/14 at approximately 11:30 AM on the Medicine Unit showed Patient #15 receiving intravenous (IV, into the vein) antibiotics for pneumonia (infection of the lungs).

9. Record review of Patient #15's IPOC showed no Pulmonary plan with nursing goals and interventions appropriate for pneumonia.

10. During an interview on 03/04/14 at approximately Noon, Staff R, RN assigned to Patient #15, and Staff Q, Clinical Supervisor, stated that the IPOC should include the Pulmonary plan with nursing goals and interventions appropriate for pneumonia. Staff Q further stated that the purpose of the IPOC is to make sure that everyone is working together toward the patient's goals.

11. Observation on 03/04/14 at approximately 2:00 PM on the Surgical Specialties Unit showed Patient #20 with an indwelling feeding tube in the stomach to provide liquid nutrition because of swallowing difficulty.

12. Record review of Patient #20's IPOC showed no Nutrition plan with nursing goals and interventions appropriate for feeding tube.

13. During an interview on 03/04/14 at approximately 2:00 PM, Staff DD, RN assigned to Patient #20, Staff BB, RN Clinical Supervisor, and Staff CC, RN Manager, stated that the IPOC should include the Nutrition plan with nursing goals and interventions for feeding tube. Staff DD further stated that the purpose of the IPOC is to make sure that everyone is working together toward the patient's goals.

14. Observation on 03/04/14 at approximately 2:30 PM on the Neurological Unit showed Patient #21 receiving IV blood thinner for a deep vein thrombosis (DVT, blood clot in the lower leg vein).

15. Record review of Patient #21's IPOC showed no Cardiovascular plan with nursing goals and interventions appropriate for DVT.

16. During an interview on 03/04/14 at approximately 2:30 PM, Staff FF, RN assigned to Patient #21, and Staff EE, RN Clinical Supervisor, stated that the IPOC should include the Cardiovascular plan with nursing goals and interventions for DVT. Staff FF further stated that the purpose of the IPOC is to make sure that everyone is working together toward the patient's goals.

17. Observation on 03/05/14 at approximately 9:00 AM on the Cardiology Unit showed Patient #34 expecting a blood transfusion for blood abnormalities.

18. Record review of Patient #34's IPOC showed it was established by Staff OO, Clinical Supervisor, and did not include the Cardiovascular plan with nursing goals and interventions appropriate for blood transfusion.

19. During an interview on 03/05/14 at approximately 9:00 AM, Staff OO stated that the IPOC should include the Cardiovascular plan with nursing goals and interventions appropriate for blood transfusion in Patient #34's IPOC. Staff OO further stated that the purpose of the IPOC is to make sure that everyone is working together toward the patient's goals.

20. Observation on 03/05/14 at 9:15 AM on the Cardiac Intensive Care Unit (ICU) showed open wounds on Patient #31's upper back.

21. Record review of Patient #31's IPOC showed no Skin/Wound plan with nursing goals and interventions appropriate for the patient's back wounds.

22. During an interview on 03/05/14 at approximately 9:30 AM, Staff TT, RN, stated that the IPOC should include the Skin/Wound plan with nursing goals and interventions appropriate for Patient #31's back wounds.

23. Observation on 03/05/14 at approximately 11:30 AM on the Surgical ICU showed Patient #43 receiving dialysis (medical procedure to remove wastes from the blood by filtering through a machine) for kidney failure.

24. Record review of Patient #43's IPOC showed the GI/GU plan did not include nursing goals and interventions appropriate for dialysis.

25. During an interview on 03/05/14 at approximately 12:30 PM, Staff HHHH, RN Educator, confirmed that Patient #43's IPOC did not include nursing goals and interventions appropriate for dialysis.